by Pamela Katz Ressler, RN, BSN, HN-BC, MS-PREP student and PREP-AIRED blog moderator
A recent study based on analysis of data from the 2004 Health and Retirement Study suggests pain hastens the aging process with respect to functional limitations at a younger age.
The study, published in the September issue of the Journal of the American Geriatrics Society, examined a sample of individuals age 50 and older living in the community. The mean age of the sample was 65. Participants who said they had significant pain — 24% of the 18,531 people surveyed — had functional limitations roughly equivalent to those of a person two to three decades older. One of the study’s authors, Kenneth E. Covinsky, MD, MPH, University of California San Francisco, wrote, “So, a 50-year-old in pain functions on the level of a 70-year-old who does not have daily pain”.
The authors of the study stated that the cross-sectional design of the study did not allow them to determine if “pain is causing functional limitations or whether functional limitations are causing pain, but it seems likely that the relationship is bidirectional.” But since the relationship appears to be powerful the study’s authors concluded that taking a more unified approach to addressing pain and function in the community setting versus only in geriatric settings may prove beneficial.
September 24th, 2009
by Pamela Katz Ressler, RN, BSN, HN-BC, MS-PREP student and PREP-AIRED blog moderator
The following article, about the Tufts University School of Medicine PREP programs, was published in the September issue of the Massacusetts Report on Nursing. We have included the full version below, to read the printed (edited for space) version, please click here (article appears on page 5)
Boston’s Hidden Gem: Pain Research, Education and Policy Programs at Tufts University
By Pamela Katz Ressler, RN, BSN, HN-BC
An unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage (medical definition)
To hear about pain is doubt: To experience pain is certainty (patient definition)
Pain is the number one reason that individuals seek medical care. As nurses, we are often faced with a lack of multidimensional pain strategies to support our patients and families living with pain. Pain has become the fifth vital sign in our assessments, but do we really have the tools and strategies to make a difference for our patients? Did you know that the only postgraduate multidisciplinary pain program in the United States is located in Boston, Massachusetts at the Tufts University School of Medicine? For me, and several other nurses who are enrolled in the Pain Research, Education and Policy Programs, it has been one of the best kept secrets around, a hidden gem in pain management education nestled in downtown Boston. Those of us involved in the Pain Research, Education and Policy Programs at Tufts University School of Medicine think it is time to raise awareness of the vital need for more pain management education taught across the disciplines and to share how our nursing practices have been enhanced by our better understanding of the many aspects of pain.
The Pain Education, Research and Policy Programs at Tufts University School of Medicine were started in 1999, by an anthesiologist/internist, Dr. Daniel Carr, and a sociologist, Dr. Kathryn Lasch. The intent was to gather many voices in the developing multidimensional and multidisciplinary approaches to the complex nature of pain. The Master of Science in Pain Research Education and Policy (MS-PREP), a 48-credit graduate degree, became the first post-graduate multidisciplinary program in the United States a decade ago and remains so to this day. Seeing the need for advanced preparation in multidisciplary pain management by professionals who currently have advanced post graduate degrees, a 20 credit Certificate of Advanced Study in Pain Topics was subsequently added to the program. Certificate students take classes with the Master degree students but also declare one of three specializations in research, education or policy, which will inform their core courses and elective choices. In 2006, the New England School of Acupuncture and Tufts University School of Medicine launched a ground-breaking joint venture by allowing student to earn both a Master of Science in Pain, Research, Education and Policy from Tufts University Medical School, as well as a Master of Acupuncture degree from New England School of Acupuncture. The many models for learning have made the Tufts University Medical School’s programs in Pain Research Education and Policy attractive for mid-career health professionals seeking advanced knowledge in pain management.
Richard Glickman-Simon, M.D. is the director of the Pain Research Education and Policy Programs at Tufts University School of Medicine, and also teaches courses on Complementary Medicine and Medical Acupuncture within the program. When asked to explain the rationale behind the unique Tufts University pain management programs, Dr. Glickman-Simon stated, “It has become abundantly clear that an overly simplistic, one-dimensional strategy is no match for the complexity and tenacity of chronic pain. Pharmacologic and surgical interventions are often essential, but they are rarely sufficient. What chronic pain sufferers require is a sophisticated, multidimensional strategy worthy of the challenge. The Pain Research, Education and Policy Programs were created for precisely this reason. Our programs encourage students to take on the problem of pain from every conceivable angle: biological, psychological, sociological, cultural, spiritual, ethical and legal. Our graduates emerge with a perspective and expertise few of their colleagues possess. More than anyone else, they have the capacity to meaningfully change the lives of people suffering from chronic pain.”
A common feature I have found among fellow R.N. students in the Pain Research Education and Policy Programs (PREP) at Tufts University is the recognition of a knowledge gap in regard to advanced pain management strategies when confronted with particularly difficult professional or personal pain situations. While the specific pain situations we confront may differ due to our individual nursing practice environments, we have all sought out the programs because we firmly believe that we can and should be able to do better in addressing and relieving the many aspects of pain in our individual patients and larger society.
I recently interviewed two current students; both experienced registered nurses, in the Pain Research Education and Policy Programs to get their perspectives on how these programs have benefited them professionally and personally. Sherry Brink is an RN working in the Day Surgical Recovery Room at Tufts University Medical Center, as well as a medical volunteer on several medical relief trips to Peru, the Philippines, and soon to China. The other student is well known to MARN members, Susan Krupnick, past president of MARN. Sherry is completing the Master of Science in Pain Education and Policy (MS-PREP) and Susan is currently enrolled in the Certificate of Advanced Study in Pain Topics
What interested you in the Pain Research Education and Policy Programs (PREP)?
Sherry Brink: “I was searching for a Masters Program that would interest me not long after finishing my RN to BSN/ BS at University of New Hampshire/Manchester. I didn’t have much luck finding a multidisciplinary program in the nursing field. When I saw PREP (Pain Research, Education and Policy Program) advertised in the hospital news, it immediately intrigued me. In my 30+ years of nursing when had I not encountered pain? Pain is found in every field of nursing practice. I was sure this Master of Science degree was something I could actually use no matter where I went.”
Susan Krupnick: “During the time I was President of the Massachusetts Association of Registered Nurses (MARN) I was attending one of the MARN clinical conferences and met Jean Connolly (former PREP programs director) who was one of the exhibitors for the Tufts University PREP programs. I had always been interested in the area of pain as it intersects in the daily work that I do as a psychiatric clinical nurse specialist and addictions nurse practitioner. So, I had a discussion with her and took some of the information documents describing the programs. I knew that at some point I would need to pursue additional education related to pain, but at that time being president of MARN and working full time was keeping me very busy. The time was not right for me to pursue additional education, but I knew the time was coming soon and this area represented a gap in my knowledge, which I believed would interfere with my clinical practice.”
Why did you decide either the MS-PREP or the Certificate program made sense for you and your nursing career?
Sherry Brink: “I’m presently working in Day Surgical Recovery at Tufts University Medical Center and as the saying goes among my peers on this unit, “pain and puke are our lives”. I knew this program (MS-PREP) would help me be more proficient at treating pain and hopefully prevent nausea in my patients.”
Susan Krupnick: “After I completed my two terms as President of MARN I still had an interest in pursuing further education in the area of pain. This turned quickly into a need to address a knowledge gap in my clinical practice very quickly. I changed my job and now was working as a psychiatric clinical nurse specialist and addictions nurse practitioner in the Emergency Department at Massachusetts General Hospital for about 18 months and, it was becoming ever apparent to me that approximately one third of the patients that I was assessing, referring and treating in the ED setting certainly had addictive illness, but also they experienced some form of pain, acute, chronic and most often neuropathic. I would work diligently to find an addiction program that could treat both their addictive illness while simultaneously treating their pain problem or at least maintain their pain medications and collaborating with their pain team members. I consistently was disappointed in the response that the patient would need to be detoxified off all their pain medications (even if they were not experiencing a problem with their prescription medication). I found this extremely disappointing and perplexing. So I turned to the literature and found no real answers there. At that time (2007) and to date there is a paucity of literature addressing the concrete issues of treating individuals with addictive illness and any form of pain, especially neuropathic pain. I had the privilege of attending a program titled Opioids, Pain and Addiction in 2007 hosted by NIDA (National Institute of Drug Abuse) and facilitated by Dr. Nora Volkow, the director of NIDA. During that program held in Bethesda, a few hundred researchers, educators and clinicians attended and heard of ongoing research, education and some future treatments that were primarily aimed at developing tamper resistant medications and novel delivery systems for opioids. Unfortunately, as the director pointed out to all of the audience that there was little research or novel programs being developed for individuals with concurrent pain and addiction and especially if treatment with an opioid might be one of the strategies to treat their pain disorder. Well I returned fueled to do something, but still knew that I had a learning curve due to my knowledge gap. Therefore, in the summer of 2008 I finally interviewed with Dr. Richard Glickman-Simon, Director of Programs for the Tufts University PREP programs to determine if my goal of knowledge acquisition about pain disorders and how best to integrate that into the care of patients with addictive illness could be met in their program. I had also searched the Internet for any other programs and found that the Tufts program was the only formally organized university level program in the United States. Fortunately for me, the Tufts program was only an hour and half away from where I live. It seemed like a good fit for my learning needs and I was impressed with the innovative nature of the programs and the discussion of the diversity of students.”
Would you say something about the program you are enrolled in, your concentration, and perhaps any faculty members or courses that have particularly influenced you?
Sherry Brink: “I’m going for the Master of Science in Pain Research Education and Policy degree (MS-PREP). In terms of inspirational faculty members, I’m still in awe of Dr Carr’s (program founder, Dr. Daniel Carr) knowledge on the subject. Respect for him and where he has taken this has inspired me.
Susan Krupnick: “I started the Certificate of Advanced Pain Topics program at Tufts University in September 2008 and am focusing on the track related to education. I have discovered that the program is very much a multidisciplinary program. During my first semester course of Neuroanatomy, Neurophysiology and Pharmacotherapy, my class colleagues were quite diverse, which was very exciting. The class participants included three nurses, a massage therapist, two physicians, and a student who had degree in genetics, individuals also from the business world. We also had students that were enrolled in the NESA program (New England School of Acupuncture). This tapestry of students made for robust and diverse discussions that exposed me to different models and theories of treating pain. This diversity has been an enriching experience for me. I am completing my second semester and have traveled along with the same students from the first semester, which has allowed me, as a student to build some relationships that I believe will last after I complete the post master’s certificate program. I have been impressed by the expertise of all the faculty members as they have done their presentations. The faculty and presenters in this program are the individuals who have done much of the groundbreaking research in their specific area of pain. I have been pleasantly surprised at their willingness to be active participants in our learning process and their enthusiasm for their research and practice is often infectious.”
How has being a student in the PREP programs influenced your nursing practice or career?
Sherry Brink: “The MS-PREP program has already affected the choices I make every day. Which pain medication to use, when, and how often. Most recovery room RN’s have a lot of leeway for making these choices. I see decisions made based on outdated information or “feelings”; not a lot of evidence based practice. There are some colleagues who will come to me for suggestions. It’s not my job to change everyone’s practice but I would like to think I have had some influence. I also have a better report with the anesthesiologists now that we discuss the different techniques in pain control. Sharing articles I have read for classes or research are of interest to the MDs. I can see they have an increased respect for me since I have started the PREP program. I have also expanded my nursing practice to include international medical mission work. I was introduced to the Medical Missions for Children by the staff from Tufts University Medical Center who had attended other missions. There was a cancellation May 08 and I was asked to join. A large group of us ended up in Lima, Peru and went to Cusco from there. It was great to see so many families waiting to be helped, some of whom received the first stage of cleft repair the previous year. I ended up being the only recovery room nurse on the trip. I used my knowledge of pain treatment for the post-op children and some adults, enough to impress the entire staff and gain some independence. We all worked hard and it was very rewarding. The Peruvian volunteers and staff were wonderful. I will return in May 2009 and see the families and staff who were such a great part of the experience. In October 2008 I was able to travel on another international medical mission trip to Leyte in the Philippines. The conditions were rudimentary but again the team pulled together and the families were so appreciative. I’m hoping my luck continues and every year I can visit another country and gain new perspective on international healthcare, especially methods of pain management. A new site is opening in China and I have asked to be part of the team. I am considering that my capstone project for the MS-PREP degree could have something to do with teaching the Peruvian hospital staff more about pain and methods of control.
Susan Krupnick: “I have already developed a more comprehensive assessment in my own practice with patients that I am consulted on an inpatient addictions unit and also in my psychiatric consultation liaison practice in an acute care hospital. I also have been discussing with leaders of institutions the idea of a research based inpatient unit that will develop an innovative program that will be multidisciplinary and the focus will be the care of the complex pain patient who also has an addictive illness. That is my ultimate goal to improve the care to this particularly challenging and often disenfranchised group of patients. “
What advice would you give to nurses who may be interested in the PREP programs?
Sherry Brink: “You have to be interested in the subject to start because it is so focused. Just spend a week making a mental note of how often you assist a patient with pain issues. If you could do it better wouldn’t you want to? Can I tell you how satisfying it is to effectively treat a patient’s pain, to see relief wash over them? It’s great! It’s part of why I stay with nursing.”
Susan Krupnick: “I would encourage any nurse who is considering further education to identify their own knowledge gaps and if the area of pain assessment and treatment is an area that they need to acquire knowledge do consider this program. The classes are diverse and that is the reality of the clinical world we work in today. I have been impressed by this program so far and believe that will continue. The faculty and leadership of the program solicit feedback from students on a regular basis, and do respond to recommendations in a prompt manner. This is truly a student-focused program and I am very satisfied with my decision to pursue this education, my practice has already been enhanced and in the long run that benefits both the patients and the staff that I consult to on a daily basis.”
For more information about this “hidden gem” of a multidisciplinary pain program nestled in downtown Boston, contact Dr. Richard Glickman-Simon, program director of the Pain Research, Education and Policy Programs at Tufts University School of Medicine (email@example.com) The Pain Research Education and Policy Programs now hosts an interactive blog (PREP-AIRED) available at http:// gotufts.edu/prep. You are welcome to join in the discussion with faculty, students and alumni working together to treat pain more effectively, efficiently, and compassionately.
Resources on Pain Management:
Tufts University Pain Research, Education and Policy (www.tufts.edu/med/education/phpd/msprep/index.html)
Massachusetts Pain Initiative (www.masspaininitiative.org)
International Association for the Study of Pain (www.iasp-pain.org)
American Society of Pain Management Nursing (www.aspmn.org)
International Association for the Study of Pain: http://www.iasp-pain.org
Scarry, Elaine: The Body in Pain, Making and Unmaking of the World, Oxford University Press, 1987.
National Institute of Arthritis and Musculoskeletal and Skin Diseases NIH Guide: “New Directions in Pain Research,” NIH Web site.http://www.niams.nih.gov/rtac/funding/grants/pa/pa_98_102.pdf.New England School of Acupuncture http://nesa.edu/pain_management_pm_2.html
September 15th, 2009
By Marcin Chwistek, MD, Attending Physician, Pain and Palliative Care Program,
Supportive Oncology Care, Fox Chase Cancer Center, Philadelphia, PA
I joined Twitter around the last elections, fascinated by social media’s power in inducing a societal change. The optimism and the real sense that we can change things for better were palpable. I had not felt anything of that magnitude since I witnessed, as a college student, the first democratic election in my native Poland in the early 1980’s. I stuck with Twitter since then, and have been primarily using it to tweet about issues related to cancer pain and palliative medicine. Over time, my community on Twitter has evolved into a fascinating mix of people: patients, medical librarians, consultants, physicians, head hunters, nurses, community organizers, news organizations, social workers and cancer advocates to name a few. And although many of them are interested in issues concerning pain management and cancer care in general, it would be incredibly naïve to think we all have common goal or even agree on things. Our backgrounds, life experiences, geography could not be more diverse. And yet, I have a sense that as a group we have a new responsibility. Clay Shirky, who has been writing about social media for a while, said this during his recent TED talk: “Old Media: professionals broadcasting messages to amateurs are increasingly slipping away. In a world where former audience are now increasingly full participants, it is less and less about crafting a single message to be consumed by individuals, it is more about environment for convening and supporting groups
. How can we best use it? ”
Traditionally, it was the pain physicians or researchers broadcasting to the community of pain patients. They might have written books on the subject, speak at a conference or for a TV program. Now it is pain patients (and again there is this amazing variety within the group – cancer pain, fibromyalgia pain, back pain etc), pain advocates, pain physicians, pain educators, pain researches organizing their own groups on Twitter, MySpace or Facebook. The groups may function as a support group, as a place to exchange ideas or perhaps as a resource. The Internet makes those goals incredibly easy. Without however committing the groups to bigger goals, more ambitious goals, goals that would affect lives of many people I am afraid we are not using the power we were given. Pema Chodron in her new book,”Taking the Leap”, writes, about “three basic qualities that have always been with us but perhaps have gotten buried and been almost forgotten”
natural intelligence, natural warmth, natural openness. I would argue that these qualities apply to groups too. There is a natural intelligence that is bigger than the sum of our individual minds, natural intelligence of the groups or “the wisdom of crowds” as James Surowiecki names it. We need to engage it as it would point naturally to what needs to be done. Natural warmth is our empathy. But hearing the stories, which being a part of online community enables, our empathy increases and we all are moved to action. Empathy is a seed of compassion, and compassion is an urge to act on behalf of those who suffer. We can choose to be moved by the stories we hear and act on them. Empathy has the power to focus our attention on issues we may have otherwise not known about. And finally, there is natural openness that Pema Chodron describes as the spaciousness of our sky-like minds. It is a beautiful metaphor, and when I think about social media, this metaphor seems to be even more powerful – Individuals working in their own seemingly separate environments, but connected on the net. It is literally “minds connecting in the sky”. Pema contrasts this attitude of openness with a fear based view “where everyone is either an enemy or a friend, a threat or an ally, someone to like, dislike or ignore.” And as anyone who has experienced it first hand, as a patient or a clinician knows, medicine is riddled with fear. There is fear of misdiagnosing the disease, fear of not being good enough, fear of not being in control, fear of being in pan, fear of not regaining ones health, fear of relationship etc. Fear seems to be in a way of most of what we do. As Parker Palmer says in one of his essays:”Fear is not just an emotion, but a central feature of the culture that surrounds us”. Being in a group, feeling a strong sense of community united to improve wellbeing of others, could be one of the best antidotes to fear. And it comes to generating a change in how medicine is practiced today; it may turn out to be our biggest asset.
September 2nd, 2009